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History and Physical Examination Admission Orders ENT/Surgery

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History and Physical Examination Admission Orders ENT/Surgery Admission Note: Patient Name: History and Physical Examination Date of Birth: Admission Orders ENT/Surgery - Adult Admission Date: Admitting Physician (FULL NAME W/MIDDLE INITIAL) *ADM NOTEPREGENA* : ADM NOTEPREGENA Preferred English Chinese Mandarin Cantonese Language Spanish Russian Other: Chief Complaint/History of Present Illness: (admit note must contain justification for surgery) Clinical History or Conditions Present On Admission: No pertinent clinical history Diabetes (please specify): Insulin Dependent Non-insulin dependent Cardiac: Myocardial Infarction Congestive Heart Failure Arrythmia Coronary Artery Disease Significant Valvular Disease Pacemaker/AICD (refer to NYEE policy on patients with defibrillator) Neuro: CVA/TIA Other: Pulmonary: Asthma COPD O2 Dependent Obstructive Sleep Apnea Other: Renal: Dialysis Heme: Deep Vein Thrombosis/Pulmonary Embolism Coagulopathy or on anticoagulant Anemia Other Hx: Hx of Multidrug-Resistant Organism (MDRO) within past 12 months Isolation status if required: Contact Other Allergies: No Known Allergies Latex If Allergies, list: Physical Exam HEENT: NCAT MMM EOMI/PERRLA Abnormal: Neck: Supple Normal ROM Trachea Midline No JVD Lymph nodes nonpalpable No carotid bruit Abnormal: Other: X Please refer to Medical Evaluation for review of systems and physical examination of pertinent organ systems other than those related to admission diagnosis ASSESSMENT/PLAN Admission Diagnosis: ICD-10 Code: Planned Procedure(s) with CPT codes: Laterality Right Left Bilateral N/A Anesthesia: General MAC/Sedation Local Other : Admission Orders: 1. Admit to Inpatient Unit Admit to Adult ASU 2. X DIET: NPO on admission 3. X IV: Insert saline lock on admission 4. Diagnostic Testing Day of Surgery (If Applicable) Diabetic patient: Fingerstick (Capillary Blood Glucose) BMP Hx of Anemia or Expected blood loss in surgery greater than 200ml Current Dialysis Patient: Serum Potassium CBC3 (WBC,HGB, PLT) AND Type and Screen Pregnancy Test; Urine Required for any patient of childbearing potential and >12 years old, or any age who has menstruated within past 12 months EKG For Age greater than 65 years old or Any patients with diabetes, HTN, cardiac, vascular, renal, or hepatic Disease Other: 5. Medical Assessment/Evaluation Medical evaluation completed by an outside Licensed Independent Practitioner within 30 days of surgical procedure Pre-Admission Testing scheduled at MS Downtown Union Square or NYEE on DATE: at TIME: Other: Resident/Fellow Signature: Print Name: Date: Time: (If Applicable) ATTENDING: Print Name: Date: Time: (Required) SURGEON ATTESTATION: I certify that I have re-examined the patient relative to the proposed surgery, reviewed the history & physical, the pre-op assessment, and spoken with the patient. Based upon all the above it is my opinion that there has not been any significant change in his/her clinical condition relative to the indications for the proposed surgery. I certify that I have re-examined the patient relative to the proposed surgery, reviewed the history and physical, the pre-op assessment and spoken with the patient. There is a change in his/her clinical condition - See Progress Note. Attending Surgeon: Print Name: Date: Time: Revised 10.15.19 ADM.072.
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